Thursday, 10 December 2015

Domestic violence and abuse: how should doctors and nurses respond? (10 December 2015)

Gene Feder

Domestic violence and abuse (DVA) is a violation of human rights with long-term health consequences, from chronic pain to mental ill-health. It is a global public health challenge, requiring political and educational intervention to drive prevention, as well as a robust criminal justice response. But what is required from front line doctors and nurses, beyond the requirement to respond with clinical competence and compassion to survivors of DVA presenting with, for example, acute injuries, pelvic pain or PTSD? What are the arguments and the evidence for an extended role for clinicians, as articulated in the NICE guidelines on DVA and the WHO guidelines on intimate partner and sexual violence, requiring specific training on DVA and the resources for referral of patients experiencing DVA to specialist DVA services?

A crucial argument and evidence source, as we move towards more patient-centred care, are that women survivors of DVA want their health care professionals to ask them about abuse and respond appropriately. In a systematic review (now almost ten years old) of 25 qualitative studies, a consistent message emerged about expectations that patients who had experienced DVA have of their doctors, which we can also extrapolate to nurses.

Before disclosure/questioning: try to ensure continuity of care and follow up (difficult for doctors and nurses in emergency settings)

Make it possible for women to disclose: ask about current and past abuse

When issue of partner violence is raised: don’t pressurise women to fully disclose

Immediate response to disclosure: ensure that the women feel that they have control over the situation and address safety concerns

Response in later consultations: understand the chronicity of the problem and provide follow up and continued support

A second argument is that training of doctors and multi-disciplinary teams improves identification of patients experiencing DVA and safe, appropriate management after disclosure. A systematic review of studies testing the effectiveness of DVA training found that training was effective, particularly if it included a referral pathway to specialist DVA or other supportive services. The crucial contribution of access to DVA services is central to the UK-wide IRIS programme of training and support for general practice teams. Based on a randomised controlled trial of that intervention, the IRIS model is now being implemented in over 30 localities in England and Wales, with a similar programme in the Scottish Lothian region.

A third argument for an extended role for clinicians with regards to DVA is based on growing evidence of effectiveness for interventions after disclosure. As discussed in our overview of health system responses to intimate partner violence, beyond first-line support that doctors and nurses can give to patients who disclose abuse, specialist DVA advocacy, cognitive behavioural and other trauma-informed psychological methods can improve women’s safety and mental health outcomes. It is tragic that, in the UK and internationally, just as the case for linkage of health services to specialist DVA services is finally being heard, the charitable sector, in which most of the specialist services are located, is being squeezed financially as part of a wider attack on the public sector.

Health care settings should be safe places where women are asked (but not screened) about DVA by doctors and nurses, can be confident of a validating response from the clinician and an offer of referral for specialist DVA support.

Author profile

Professor Gene Feder is a Professor of Primary Healthcare at the University of Bristol. His research interests are in cardiovascular medicine and domestic violence. Gene held the chair of primary care research and development at Barts and the London (QMUL) until 2008. He chaired 4 NICE clinical guidelines (Lipid management in type II diabetes, Falls in older people, Secondary prevention of MI, Domestic violence and abuse) and the WHO intimate partner violence guideline development group.